DET PSYKOLOGISKE FAKULTET
Ψ
Continuity between waking life and dreams of psychiatric patients A review and discussion of the implications for dream research
HOVEDOPPGAVE profesjonsstudiet i psykologi
Joacim F. Skancke
Høst 2013
Veileder: Ingrid Holsen
Preface
Writing this thesis has been a real challenge. I have long been interested in dreams personally, but did not think of the possibility of writing about them in my thesis until quite late. As a result, I have had a suboptimal time limit within which I had to dismiss all the work I had done on my original subject, and start up with the subject of dreams.
Through the process I have learned a lot about dreams and, of course, about writing a literature review, and I am very glad I chose to change subject.
I was very fortunate to receive positive response from dream researcher Michael Schredl when I asked if he would co-supervise my thesis. His extensive knowledge of the field of dream research has been invaluable in my exploration of the field, and in writing this thesis. He also provided me with the belief that I could to write a thesis which could be published. As a result, this thesis is ready to be peer-reviewed and published in International Journal of Dream Research. The online format of this journal allows the thesis to be published in its full length.
I would like to thank my supervisor Ingrid Holsen for providing me with clear directions in terms of what parts of the paper needed improvement. She also provided me with the perfect location to write my thesis in quiet concentration. Without her help the quality of this thesis would not have been half of what it is now.
I would finally like to thank my friends, family and girlfriend. Your love and support is what keeps me going every day.
Abstract
Despite positive results from the use of dreams in psychotherapy and for personal growth, little is known of their nature and function. As an approach to expand our knowledge of dreams, their relationship to waking life of the dreamer have been investigated. Several patterns of connection between waking life and dreams has been identified, resulting in the so called continuity hypothesis of dreaming. Yet the
formulation of this hypothesis remains too vague to thoroughly account for the relationship between waking life and dreams. To increase our knowledge of this relationship, the existing literature on dreams of psychiatric patients were reviewed in the present thesis, to identify the continuities and discontinuities between the dreams and the waking life psychopathology of these patients. This is an area of dream research not often approached. The findings demonstrate that several aspects of the waking life psychopathology of the patients show both continuity and discontinuity in dreams. The results indicate that a more specific and comprehensive definition of continuity is needed, and that more attention must be granted to the phenomenon of discontinuity.
Furthermore, assessments of specific symptoms should compliment the patients’
diagnoses for comparisons with dreams to be meaningful.
Keywords: Dreaming, continuity, discontinuity, mental disorders, psychiatric patients, dream content, waking life
Sammendrag
Selv om det foreligger positive resultater fra bruk av drømmer i psykoterapi og for personlig vekst, finnes det lite sikker kunnskap om deres natur og funksjon. For å forsøke å forstå mer av drømmer har sammenhengen mellom drømmerene og personens våkne liv blitt undersøkt. Våkent liv og drømmer er vist å henge sammen på flere måter, noe som har ført til formuleringen av den såkalte kontinuitetshypotesen om drømmer.
Denne hypotesen er imidlertid for vag til å fullt ut forklare forholdet mellom våkent liv og drømmer. For å øke kunnskapen om dette forholdet, gjennomgår jeg i denne
hovedoppgaven forskningen på drømmer fra psykiatriske pasienter, med mål om å identifisere kontinuitet (og diskontinuitet) mellom drømmene og pasientenes psykiske sykdom. Dette er et felt innenfor drømmeforskning som er blitt relativt lite undersøkt.
Funnene fra denne oppgaven viser at flere aspekter av pasientenes psykiske sykdom viser både kontinuitet og diskontinuitet i drømmene. Resultatene indikerer at en mer spesifikk og omfattende definisjon av kontinuitet behøves, samt at mer oppmerksomhet bør tildeles fenomenet diskontinuitet. Samtidig bør man måle spesifikke symptomer i tillegg til pasientenes diagnoser for at sammenlikning med drømmer skal være meningsfylt.
Table of contents
Preface i
Abstract ii
Sammendrag iii
1. Introduction 1
1.1 The Continuity Hypothesis 3
1.2 The Aim of This Review 5
2. Method 6
3. Results 9
3.1. Schizophrenia 10
3.2. Depression 13
3.3. Anxiety Disorders 16
3.4. Personality Disorders 18
3.5. Eating Disorders 19
3.6. Obsessive-Compulsive Disorder 21
4. Discussion 22
4.1. Findings Supporting the Continuity Between Waking and Dreaming 22
4.2. Findings Reflecting Possible Discontinuities Between Waking and Dreaming 28
4.3. Implications for the Continuity Between Waking and Dreaming 35
4.4. Adequacy of Diagnoses as Waking Life References 37
4.5. Methodological Issues in Dream Research for Psychiatric Patients 39
4.6. Directions for Future Research 41
4.7. Conclusive Remarks 42
5. References 43
The mental activity of dreaming has fascinated people for ages. These mysterious scenes and images of the night can stir up the strongest of emotions, and feel as real as experiences of the waking life. Some of the earliest written records of dream reports that have been found are clay tablets documenting dreams from people in the early
Mesopotamian civilizations in the third millennium BC (Bulkeley, 2008). As for modern people’s interest in dreams, King and DeCicco (2009) found in a sample of university students that 81% believed their dreams to contain important information.
Similarly, Morewedge and Norton (2009) found that the majority of their participants, from both eastern and western cultures, believed that dreams contain hidden truths, and considered information presented in dreams to provide more important information about the world than similar waking thoughts. Clearly, dreams continue to fascinate us today.
Many attempts at an explanation of the cause and purpose of dreams are set forth. The theories ranges from the view of dreams as nothing but a biological epiphenomenon with no purpose (Flanagan, 1995), to the view that dreams are messages from the divine (Bulkeley, 2008). Yet no consensus exists in the scientific community for any explanation of this nightly phenomenon and its relation to
personality, emotions and waking life experiences. The usefulness of dreams as tools for waking life is also debated. Nevertheless, since the early 1900s, with the publication of The Interpretation of Dreams by Sigmund Freud (Freud, 1953), dreams have been utilized by psychotherapists as a therapeutic tool. An increasing number of studies have demonstrated the different ways in which the application of dreams in therapy have been successful as an aid both for diagnosis (Ishida et al., 2010), treatment (Gilchrist, 2013; Knudson, 2006; Widen, 2000), therapy progression (Kramer & Glucksman, 2006)
and prognosis (Cartwright, Young, Mercer, & Bears, 1998; Kramer, 2000). Dreams can help clients gain insight about themselves, increase their therapy involvement, ease the access to central issues, facilitate a safe environment for exploring oneself, and aid the therapist’s understanding of the client and his or her progress in therapy (Pesant &
Zadra, 2004). For some patient groups more resistant to therapy, exploring issues and emotions through dreams have proven to be a good alternative (Brink & Allan, 1992).
Positive results have also come from using dreams in couples therapy (Kolchakian &
Hill, 2002) and group therapy (Falk & Hill, 1995). In addition to therapy, the use of dreams by healthy individuals for personal growth has been pointed out to be both valuable and underestimated in terms of its usefulness (Berube, 1999; Ullman, 2006).
Furthermore, dreams have also been demonstrated to enhance waking life creativity (M.
Schredl & Erlacher, 2007), by yielding inspiration for artwork, solving work-related problems, motivating the dreamer to deal with a difficulty in his or her life, and providing emotional insights.
In spite of the many indications of the benefits of dreams, the use of them remains limited. There are several reasons for this. Even though the use of dreams is demonstrated to be effective, much uncertainty still exists regarding exactly what aspects of dream work is effective (Pesant & Zadra, 2004). Furthermore, as science is unable to determine the nature and function of dreams, the development of a reliable procedure of utilizing them effectively is impeded. This lack of facts and established guidelines, as well as the subjective nature of dreams, probably prevents many from exploring them, personally and scientifically. For instance, feeling a lack of competence in working with dreams causes many clinicians to abstain from utilizing their patients’
dreams in therapy (Crook & Hill, 2003).
1.1 The Continuity Hypothesis
As a way of studying the nature and function of dreaming, research has aimed at investigating the relationship between dream content and waking life. The findings of this research has accumulated in what has been coined “the continuity hypothesis of dreaming”, which states that dreams reflect waking-life (for a review see Domhoff, 1996; M. Schredl, 2003). Many research findings support this hypothesis, and certain patterns of connection between waking-life and dreaming are identified (Gilchrist, 2013; Hartmann, 2000; Hartmann, Rosen, & Rand, 1998; M. Schredl, 2006; M. Schredl
& Hofmann, 2003; M. Schredl & Reinhard, 2009; M. Schredl, Schäfer, Hofmann, &
Jacob, 1999). For instance, dreams have been found to be affected by waking life aspects such as emotions (Gilchrist, 2013), stress (Breger, Hunter, & Lane, 1971), personality characteristics (Gilchrist, 2013; Hartmann et al., 1998), psychopathology (Brink & Allan, 1992), and level of well-being (Pesant & Zadra, 2006). Pesant and Zadra (2006) demonstrated that the lower the participants’ level of daytime
psychological well-being, the more their dreams contained negative emotions, aggressive social interactions and failures.
However, despite the many findings in favor of the continuity hypothesis, much uncertainty still surrounds it, as the exact formulation of the hypothesis remains vague.
M. Schredl and Hofmann (2003) have demonstrated that a general formulation of the continuity hypothesis is not valid, as some aspects of waking life, such as cognitive activities like reading and writing, are reflected in dreams less often than other aspects.
It has been suggested that threatening events are incorporated more often in dreams (Revonsuo, 2000). This is questioned, however, by the finding that emotional tone does not affect the incorporation rate, i.e., negative events are not incorporated more frequent
than positive events (M. Schredl & Reinhard, 2009). Furthermore, the time passed since the event and at which time of the night the dream is collected from seem to affect the rate of incorporation of waking life into dreams (M. Schredl, 2006). Several authors emphasize that dreams deal mostly with personal and emotional concerns (Domhoff, 1996; Hall, 1953; Hartmann, 2011). This is supported by research showing that the emotional intensity of an experience increases its incorporation rate (Michael Schredl, 2006), but more support is still needed. In short, there is a need for a specification of what waking life aspects are incorporated into dreams, to what degree, and what affects the incorporation rate.
Another point of discussion is how waking life is portrayed in dreams. One perspective is that to be continuous with waking life, the dream scene must be a realistic replica of a waking event. Another perspective is that dreams portray our subjective conceptions of events (Hall, 1953), like visual metaphors for experience (Malinowski &
Horton, 2011). This latter perspective expands the possibilities for continuity, by allowing even unrealistic dream scenes to be continuous with how the dreamer subjectively experienced an event. Fosse, Fosse, Hobson, and Stickgold (2003) demonstrated that only 1-2% of dreams contain more or less exact replicas of waking life events, indicating that dreams mostly incorporate waking life in more creative ways than by direct copy.
In addition to the uncertainties surrounding the continuity hypothesis, it is apparent that the continuity hypothesis does not by far explain the relationship between waking and dreaming in its totality. On the contrary, studies have also identified
discontinuities, like flying unaided in dreams, an experience no one has in waking life.
The causes and purpose of this is so far unknown.
In short, the specification and revision of the continuity hypothesis is an ongoing debate (Hobson & Schredl, 2011), attempting to integrate the fact that dreams also contain discontinuous elements. Such a specification is crucial to increase our understanding of the relationship between waking life and dreams.
1.2. The Aim of This Review
A considerable amount of research exists on the dreams of healthy individuals.
The research on dreams of psychiatric patients, on the other hand, is more scarce.
Reviews of this research has been done in the past (Kramer, 1970, 2000, 2010; Kramer
& Nuhic, 2007; Kramer & Roth, 1978; Mellen, Duffey, & Craig, 1993; Ramsey, 1953).
These reviews examined the research on the content of the patients’ dreams to understand the development and causes of psychopathology (Kramer, 2010), and to uncover the potential of dream content as a diagnostic tool (Mellen et al., 1993). No review has so far thoroughly investigated the continuity between waking and dreaming for psychiatric patients. However, the effect of mental disorders on waking life are substantial. Consequently, the effect on dreams might also be notable, making investigations of the dreams of psychiatric patients a potential source of valuable information about the relationship between waking life and dreams. The aim of the present paper is, therefore, to identify the continuities and discontinuities between dreams and waking life of psychiatric patients, in order to contribute to our
understanding of the relationship between waking life and dreams. This aim will be approached in the following manner: First, by reviewing available studies and previous reviews of dreams of patients diagnosed with one of the main mental disorders (i.e., schizophrenia, depression, anxiety disorders, personality disorder, eating disorders and obsessive compulsive disorder). Characteristics in the dreams of these patients will be
identified and presented in the result section. The focus will be on dream content, but nightmare frequency and effect of therapy will also be included. Second, continuities and discontinuities between the dreams and the waking life and symptomatology of the patients will be highlighted in the discussion part of the paper. Lastly, based on the findings, the implications for the understanding of the continuity between waking and dreaming will be discussed. Methodological issues in the field of dream research as well as the directions for future research will also be considered.
2. Method
The present paper is a review of the aforementioned reviews on dream content for patients with mental disorders, including a systematic literature search to the present date. The earliest review (Ramsey, 1953) is not included as the reliability and relevance of its findings are inadequate. Neither is the review from 1970 (Kramer, 1970), as the studies it reviewed are also found in the later reviews. A different set of diagnoses is included in present review, compared to the previous reviews. More details of this will be given shortly.
The literature search was performed in August and September 2013, screening the data bases PsycINFO, PubMed and MEDLINE for articles in English. PubMed accesses the same database as MEDLINE, but was included to increase the scope of the search, as the searches on MEDLINE were performed by mapping the term to subject headings. This makes the search more focused, but increases the risk of missing relevant articles. PubMed, on the other hand, searches fields beyond just subject headings, such as abstracts and full texts.
In MEDLINE and PsycINFO subject headings searched were
“Dreams”/”Dreaming”, paired with “Mental Disorders”, “Schizophrenia”,
“Depression“/”Major Depression”(and “Recurrent Depression”, Treatment Resistant Depression, Atypical Depression, and “Long-term Depression (Neuronal)”), “Anxiety Disorders”, “Eating Disorders”, “Obsessive-compulsive Disorder”, “Personality
Disorders”, and “Psychopathology”. The “autoexplode” and “focus” functions were not used.
Search terms used in PubMed were “Dream*(-s, -ing)” paired with “Mental disorder*(-s)”, “Schizophreni*(-a, -ic)”, “Depressi*(-on, -ve)”, “Anxiety disorder*(-s, - ed)”, “Eating disorder*(-s, -ed)”, “OCD OR Obsessive-compulsive”, “Personality disorder*(-s, ed)”, and “Psychopathology”.
The searches were limited to articles published in 2005 or later, as studies published earlier than 2005 are covered in the previous reviews, with some exceptions:
The only review dealing with anxiety disorders and personality disorders included studies published in 1990 or earlier (Mellen et al., 1993), whereas obsessive-compulsive disorder (OCD) has never been included in a review on dream content. For the present paper the search for the two former disorders therefore included studies from 1990 or later, while the search for studies on the latter disorder had no time limit. In addition, relevant studies referred to in the obtained articles were collected, as well as studies citing the obtained articles.
Inclusion criteria were studies with n>1, i.e., not case studies, as the
generalizability of findings from case studies is very limited. In addition, the studies had to investigate either dream content, nightmare frequency or effect of therapy on
dreaming for patients with one of the six following mental disorders; schizophrenia, depression (including bipolar disorder), anxiety disorders, personality disorders, eating disorders, and OCD. The findings on OCD are reported separately from the findings on
anxiety disorders, even though OCD is an anxiety disorder. The reason is that the empirical studies available are on anxiety disorders in general, and on OCD separately.
It is therefore considered to be of interest to separate the findings in the present review as well, to emphasize any differences between dreams of anxiety disorders in general and OCD.
Bipolar disorder is separated from depressive disorders in the most recent edition of Diagnostic and Statistical Manual of Mental Disorders, the fifth edition (DSM-V; American Psychiatric Association, 2013). Bipolar disorder is, however, included as a depressive disorder in the present review, as it was classified as a depressive disorder when the studies included in the present review were conducted.
Dreams of patients with post-traumatic stress disorder (PTSD) were not
included, as recurrent, distressing dreams are symptoms of PTSD (American Psychiatric Association, 2013), and might be a failure in dream function (Kramer, 1991). It is therefore not considered helpful to study continuity between the dreams and current waking life of these patients.
Nightmare disorder was part of the previous reviews, but is not included in the present review. Nightmare disorder is not one of the main mental disorders, but a parasomnia, i.e., disturbed dreaming is the core symptom and not waking life symptoms, making searches for continuity unsuitable. Instead, studies on nightmare frequency for the different mental disorders were included, as nightmares can be considered dreams with highly negative affect. Thus, nightmare frequency might
convey information of the rate of daytime negative affect incorporated into dreams (i.e., the rate of continuity).
The previous reviews included disorders with an organic basis and alcohol and substance abuse related disorders, but the focus in the present paper is on more “pure”
forms of mental disorders. Furthermore, studies investigating symptoms of mental disorders in the general population were not included, to limit the findings only to people displaying pathological levels of symptoms, i.e., patients diagnosed with a mental disorder.
In addition to the databases mentioned, other search engines and databases were used, such as Google, Google Scholar, Web of Knowledge and International Journal of Dream Research.
3. Results
Searching the three databases yielded 379 studies, of which 18 were included for further analysis: six on schizophrenia (Khazaie et al., 2012; Lusignan et al., 2010; Lusignan et al., 2009; Noreika, Valli, Markkula, Seppala, & Revonsuo, 2010; Scarone et al., 2008;
Zanasi, Calisti, Di Lorenzo, Valerio, & Siracusano, 2011), one on anxiety (Nadorff et al., 2013), five on depression (Cartwright, Agargun, Kirkby, & Friedman, 2006; M.
Schredl, Berger, & Riemann, 2009; Tribl, Wetter, & Schredl, 2013; Zanasi, Pecorella, Chiaramonte, Niolu, & Siracusano, 2008; Zervas & Soldatos, 2005), four on personality disorders (Guralnik, Levin, & Schmeidler, 1999; M. Schredl et al., 2012; Semiz,
Basoglu, Ebrinc, & Cetin, 2008; Simor & Horvath, 2013), two on OCD (Kuelz, Stotz, Riemann, Schredl, & Voderholzer, 2010; Sauteraud, Menny, Philip, Peyre, & Bonnin, 2001), and one on schizophrenia and depression (Limosani, D'Agostino, Manzone, &
Scarone, 2011). In addition to this, four studies were found via references in articles, books and other internet-based databases: one on depression and schizophrenia (Mume, 2009), one on personality disorders (Simor, Csoka, & Bodizs, 2010), one on eating
disorders (Zanasi, Chiaramonte, Paoletti, Testoni, & Siracusano, 2010), and one on several disorders (Swart, van Schagen, Lancee, & van den Bout, 2013). This amounted to a total of 23 studies analyzed, in addition to the previous reviews. Certain studies published prior to 2005 were obtained, analyzed and cited to provide more specific information of the findings. This applied to findings which the previous reviews yielded unsatisfactory amounts of information on, or to studies which seemed not to be included in the previous reviews.
The number of studies included in the previous reviews ranged between 35 (Mellen et al., 1993) and 173 (Kramer, 2010) studies. The latter number is probably the most representative for the number of studies published up until 2005, as this was from the most recent review, which included studies from two previous reviews (Kramer &
Nuhic, 2007; Kramer & Roth, 1978).
It must be noted that nightmare frequency and effect of therapy on dreaming was not found for all disorders.
3.1. Schizophrenia
3.1.1. Dream content. More hostility in dreams of schizophrenics than dreams of controls is reported to be one of the most consistent findings (Kramer, 2010). The hostility is mostly directed at the dreamer, yet it is less likely that the patient is the focus of the dream (Kramer, 2010). Zanasi et al. (2011) also found that schizophrenics are never the main character in their dreams.
More anxiety in dreams of schizophrenics is another of the most consistent findings reported by Kramer (2010). Hadjez et al. (2003), however, did not find more anxiety in dreams of their sample of adolescent schizophrenics than healthy controls.
They further found that the schizophrenics had less involvement and emotional
expression in their dreams. Controls had more vivid, rich and elaborate dreams. Zanasi et al. (2011) also found the dreams of their sample of adult schizophrenics to display reduced emotional expression. Lusignan et al. (2009) found dreams of schizophrenics to contain less neutral emotions than dreams of controls. The frequency of positive and negative emotions was equal between the two groups. It must be noted, however, that after controlling for dream length, only more strangers in schizophrenics’ dreams remained significant in the study by Lusignan et al. (2009). Hadjez et al. (2003) further found that more negative schizophrenic symptoms predicted less involvement and emotion in the dreams. In contrast, Khazaie et al. (2012) found negative and positive symptoms in the schizophrenic patients to be unrelated to dream content.
The type of characters appearing in dreams of schizophrenics seem to differ from the characters in dreams of healthy controls. Kramer (2010) reported that in dreams of schizophrenics the most frequent characters are strangers, and that males and groups of people appear more often. Lusignan et al. (2009) also found dreams of schizophrenics to contain more strangers, as well as fewer familiar characters. Khazaie et al. (2012) found fewer friends in the dreams of schizophrenics compared to healthy controls. Okuma, Sunami, Fukuma, Takeo, and Motoiku (1970) also found fewer friends in schizophrenics’ dreams, and more family members. In terms of locations of the dream scenes, Zanasi et al. (2011) found that the scenes in dreams of schizophrenics are mainly located indoors, in contrast with controls.
More bizarreness and implausibility in dreams of schizophrenics compared to non-schizophrenics is also reported by Kramer (2010) as one of the most robust
findings. However, the studies Kramer (2010) refers to are quite old and the more recent studies offer a more diverse impression: Noreika et al. (2010) found that the
schizophrenics’ dreams were more bizarre than healthy controls’. Scarone et al. (2008) and Limosani et al. (2011) on the other hand, found no difference in dream bizarreness between schizophrenics and controls, even though the waking mentation of
schizophrenics were found to be more bizarre than that of controls. The results of Okuma et al. (1970) also support equally bizarre dreams for schizophrenics and non- schizophrenics. Lusignan et al. (2009) found a methodologically caused difference;
whereas external judges rated the dreams of both schizophrenics and controls equally bizarre, schizophrenics rated their own dreams less bizarre than controls did. In a similar manner, Lusignan et al. (2010) found that controls reported a feeling of
bizarreness for their REM dreams, whereas the schizophrenics did not. Furthermore, in the study by Hadjez et al. (2003) external judges found dreams of schizophrenics to be less implausible than controls. In a sample of psychiatric inpatients, including
schizophrenics, M. Schredl and Engelhardt (2001) found that the dreams of the patients were less bizarre than those of controls. However, the schizophrenics had more bizarre dreams than the rest of the patients, and the “paranoid ideation” and “psychoticism”
scales of the symptom checklist correlated positively with bizarreness in the dreams of the patients. Thus, research findings on dream bizarreness for schizophrenics are mixed.
3.1.2. Nightmare frequency. Regarding nightmares for schizophrenic patients, both (Mume, 2009) and Lusignan et al. (2009) found that schizophrenic patients report significantly higher frequency of nightmares compared to controls.
3.1.3. Effect of therapy on dreaming. Kramer and Nuhic (2007) reported that a decrease in affect in dreams is the first change seen during successful treatment with phenothiazine.
In summary, the available research indicates that compared to controls dreams of schizophrenics are shorter, contain more hostility, more strangers, with the dreamer rarely being the main character. Results are inconsistent on the level of bizarreness, whereas nightmares seem more prevalent in schizophrenics than controls.
3.2. Depression
3.2.1. Dream content. Even though most dream characteristics are similar to those of controls, several distinct differences in dream content have been found (Kramer, 2010). One of the most stable findings in dreams of depressed patients
concerns the type of characters included, whereby family members are more frequent in dreams of depressed (Kramer, 2010).
Mellen et al. (1993) reported in their review that dreams of depressed contain greater negative mood tone. Similarly, negative dream emotions were related to
intensity of depressive symptoms and anxiety in a large sample of depressed outpatients (M. Schredl et al., 2009). Furthermore, in the latest review (Kramer, 2010) it is stated that dreams of depressed contain more failures and misfortunes than schizophrenics’
dreams. However, in the same review it is stated that dream reports of depressed contain less traumatic or depressive content than dreams of non-depressed, during a depressive episode and after remitted depression (Kramer, 2010). Also, Cartwright et al. (2006) found that depressed patients reported less negative and more neutral affect in their dreams compared with the control group. Lastly, Schredl & Engelhardt (2001) found no difference in emotional tone or emotional intensity between dreams of depressed and controls.
Mellen et al. (1993) concludes that dreams of depressed patients frequently has a time orientation focused on the past. This was found earlier by Hauri (1976). In his
review of 2010, however, Kramer draws a different conclusion, stating that past focus is not always found in, nor unique to, dreams of depressed.
Affects like anxiety and hostility are not often found in dreams of depressed, and their dreams contain more friendly and fewer aggressive interactions than
schizophrenics’ dreams (Kramer, 2010). If hostility is present it is directed toward and away from the dreamer with similar frequency, in contrast with schizophrenics’ dreams, where hostility is usually directed at the dreamer (Kramer, 2010). This differs from the review of Mellen et al. (1993) where it is stated that in dreams of depressed, anxiety and threat are mostly directed inwards toward the dreamer. A finding of the depressed patients’ behavior in their dreams comes from Zanasi et al. (2008), demonstrating that depressed patients have a more passive role in their dreams.
Bipolar depressed patients (though not a depressive disorder in DSM-V;
American Psychiatric Association, 2013) are found to report more dreams with death themes than unipolar patients, and to have dreams with themes of death and injury prior to shift to mania (Beauchemin & Hays, 1996). Limosani et al. (2011) found daytime cognition of bipolar patients to be more bizarre than that of controls, and equally as that of schizophrenics. Dreams on the other hand were similarly bizarre for all groups. On the other hand, M. Schredl and Engelhardt (2001) found that the depressed patients, as well as the other non-depressed patients, reported less bizarre dreams with more physical interaction, compared to healthy controls.
Even though earlier studies (e.g., Beck & Hurvich, 1959) indicated that masochism (e.g., rejection, disappointment and humiliation) is prevalent in dreams of depressed patients, the more recent review of Kramer (2010) conclude that this is not
so. Masochism seems more common in depressed women, and then more likely a trait characteristic (i.e., not attributable to the depression; Kramer 2010).
Thoughts and attempts of suicide have been found to affect dream content.
Kramer (2000) reported findings of increased incidence of death themes in dreams of depressed suicide attempters. In concordance with this, Mellen et al. (1993) reported in their review that dreams of depressed who had attempted suicide had more death
content, destructive violence, masochistic ideation and apprehension than dreams of less depressed clients. Dreams of patients with thoughts of suicide but no suicide attempt contained little death content, but masochistic reference and intense anxiety Mellen et al. (1993). Severely depressed patients dreamed more often about death and aggression than mildly depressed patients (Schredl & Engelhardt, 2001). Mellen et al. (1993) further characterizes dreams of mildly depressed persons as noteworthy for containing themes of loss and abandonment.
3.2.2. Nightmare frequency. Research on nightmares and depression generally indicates that patients with depression, and symptoms of psychopathology in general, experience significantly higher rates of nightmares (Hublin, Kaprio, Partinen, &
Koskenvuo, 1999; Kales et al., 1980; Mume, 2009; Swart et al., 2013; Zervas &
Soldatos, 2005).
3.2.3. Effect of therapy on dreaming. Kramer, Whitman, Baldridge, and Ornstein (1968) reports that clinical improvement in depression, following use of antidepressant treatment, leads to decreased hostility in their dreams, while intimacy, motility and heterosexuality increases. Also, two other studies have found that dream emotions become more positive during treatment with trimipramine (Riemann, Löw, Schredl, & Wiegand, 1990; M. Schredl et al., 2009). Conversely, Armitage, Rochlen,
Fitch, Trivedi, and Rush (1995) found no effect of medications (SSRI and nefazodone) on dream content despite daytime symptom improvement. A possible explanation to these divergent findings might be that the medications used have some divergent effects (Tribl et al., 2013).
In summary, several unique characteristics are found in dreams of depressed.
Among these are shorter dreams, and more family members. However, due to a limited number of studies, as well as methodological issues in the existing studies, only few findings can be reported as being relatively certain.
3.3. Anxiety Disorders
The following findings on dream content for patients with anxiety disorders are taken from a single study by (Gentil & Lader, 1978). Four other studies (Desroches &
Kaiman, 1964; Nadorff et al., 2013; M. Schredl, Kronenberg, Nonnell, & Heuser, 2001;
Swart et al., 2013) were found, but these dealt exclusively with the relation between nightmare frequency and anxiety disorders.
3.3.1. Dream content. The anxiety patients had significantly less activity and successfully accomplished goals in their dreams compared to both high-anxiety and low-anxiety controls. The dream content of the patients also expressed significantly more failure and sadness.
The dreams of the anxiety patients contained more social interactions in total, less friendly interactions and more aggressive interactions. The frequency of dream reports in which the aggression was directed at the dreamer increased linearly with increase in daytime anxiety. That is, in the dreams of the low-anxiety normals no aggression was directed toward the dreamer, in the dreams of the high-anxiety group 46% of the aggression was directed at the dreamer, and in the patients’ dreams 60%.
The aggression typically fell in one of two categories; either ‘creatures’ or ‘strangers’
attempting to physically harm the dreamer, or the dreamer being rejected or abandoned, usually by the husband or another known male person. The latter category was the most common.
Dream content correlated significantly with most of the aspects of daytime aes tested, illustrated by the following examples: Successful goal accomplishment in dreams corresponded to the subjects’ ratings of their waking life and themselves as more successful; and increased apprehension in dreams corresponded to tension in waking life. Interestingly, one single measure of daytime attitudes showed an inverse relationship with the frequency of the corresponding dream element: The more the daytime category ‘the human body’ was labeled as ‘tense’, the more references to body parts were found in dreams, contrary to the authors’ expectations.
3.3.2. Nightmare frequency. Desroches and Kaiman (1964) demonstrated that subjects diagnosed with an anxiety disorder had significantly higher frequency of frightening dreams than the control group. Similarly, Swart et al. (2013) found a markedly increased frequency of nightmare disorders in patients with an anxiety disorder (15,6%), compared to the prevalence in the general population (2-5%). And lastly, Nadorff et al. (2013) found that older adults with generalized anxiety disorder (GAD) had more bad dreams than those without GAD. Schredl et al. (2001) on the other hand, found that patients with panic attacks reported similar frequency of nightmares as controls.
Summed up, negative themes like rejection, aggression, failure, passivity and sadness seem to be more common in dreams of anxiety disorder patients compared to controls. The available research on nightmares and anxiety disorders, though limited,
seem to indicate that nightmares are more prevalent in most of these patients than in the general population.
3.4. Personality Disorders
Only Mellen et al. (1993) have done a review that included description of
dreams for this patient group. They included six studies, dealing mostly with nightmares and night terrors. Five more studies were found published after 1990 (Guralnik et al., 1999; M. Schredl et al., 2012; Semiz et al., 2008; Simor et al., 2010; Simor & Horvath, 2013).
3.4.1. Dream content. In the study by Simor et al. (2010), the BPD patients rated their own dreams more distressing than the controls did. There was also a tendency for the dreams of the patients to have longer effect on waking mood, though this did not reach significance. Similarly, M. Schredl et al. (2012) found that BPD patients reported dreams with a more negative emotional tone than the healthy controls did. The patients with comorbid post-traumatic stress disorder (PTSD) tended to report even more negatively toned dreams, but this was not significant. When external judges rated the dreams, no difference in dream emotions was reported. General characteristics of the dream (number of dream persons, bizarreness, and occurrence of verbal and physical interaction) were not different between patients and controls in the study by Schredl et al. (2012). Neither were borderline specific symptoms such as strong
emotional shifts or injuries of the dream ego, which occurred very rarely. Health related topics, on the other hand, was reported more by the patients than controls, especially those without comorbid PTSD (M. Schredl et al., 2012).
Guralnik et al. (1999) studied the dreams of patients with various personality disorders (PD). Surprisingly, the dreams of the PD group contained more friendly and
less aggressive interactions than the control group (using Hall and Van de Castles (1966) norms).Furthermore, the dreams of the patients contained less apprehension and confusion than the dreams of the controls. The patients had more unfamiliar and
ambiguous settings in their dreams, and a trend toward more strangers, though this was not significant. Of other reported dream activities, the patients reported more
movement, as well as auditory, verbal and thinking activities. And finally, a far greater proportion of both of the groups’ dreams ended with misfortune than with a positive outcome, with no significant difference between the groups.
3.4.2. Nightmare frequency. Mellen et al. (1993) reported that the occurrence of a personality disorder have been connected with higher incidence of nightmares.
They also reported that patients with BPD and schizotypal personality disorder suffer more often from lifelong nightmares than the general population. Several other studies have found more frequent nightmares in BPD patients (M. Schredl et al., 2012; Semiz et al., 2008; Simor et al., 2010; Simor & Horvath, 2013). Semiz et al. (2008) further found that BPD patients with comorbid nightmare disorder (ND) showed more severe
psychopathology than BPD patients without ND.
Conclusively, patients with BPD seem to rate their dreams as more distressing and with a more negative emotional tone than controls. The available research indicates that patients with personality disorders have a higher frequency of nightmares than the general population.
3.5. Eating Disorders
3.5.1. Dream content. Eating disorder patients frequently dream of food, bulimics more so than anorexics (Kramer, 2010; Mellen et al., 1993). Similarly, Zanasi et al. (2010) demonstrated that references to food occurred four times as frequent in the
dreams of anorexic patients than dreams of controls. M. Schredl and Montasser (1999) reported a difference between anorectic and bulimic patients; whereas the bulimics dreamt more than controls about food, anorexics dreamt more of rejecting food.
Zanasi et al. (2010) found that the dreams of anorexic patients displayed reduced expression of emotions compared to controls. In contrast, Mellen et al. (1993) reported dreams of eating disordered patients to be vivid and emotional. Both M. Schredl and Montasser (1999), Frayn (1991), and Brink and Allan (1992) found more negative emotions and increased emotional intensity in dreams of eating disordered compared to controls. Schredl and Montasser (1999) further showed that dreams of bulimics
displayed reduced frequency of positive emotions compared to controls. Kramer (2000) reported that anorexics seem more anxious in their dreams compared to other groups.
Frayn (1991) found fewer pleasurable themes and fewer dreams in color in dreams of anorexics compared to controls. In their dreams the anorexics often looked younger than their actual age, and they frequently dreamt of having a distorted body, e.g., enlarged belly (Frayn, 1991). Increased references to body distortions was also found in Brink and Allans (1992) study, but not in Schredl and Montasser’s (1999) study.
Kramer (2000) reported that eating disordered patients may have less hostility in their dreams compared to controls, with bulimics having more hostility than anorexics.
In contrast, (Mellen et al., 1993) states that eating disordered often dream of being the recipient of violence.
Brink and Allan (1992) found that compared to controls the eating disordered patients had increased frequency in their dreams of the following scenarios or feelings:
A sense of impending doom at the end of the dream, ineffectiveness, an attitude of inability to succeed, being attacked by a person, animal or thing, and anger. Brink,
Allan, and Boldt (1995) further identified the following themes in dreams of the eating disordered: Self-hate, a sense of being controlled by others, a sense of being watched and judged, and an inability to self-nourish.
Zanasi et al. (2010) demonstrated that the patients reported their dreams more often in present tense, in a non-linear fashion, and that the patients’ dreams lacked indicators of context.
In conclusion, research indicate that dreams of eating disordered patients contain more references to food, as well as differing from dreams of controls in terms of
emotional tone and expression. Several other characteristics have been found in the dreams of these patients, but replication of these results are lacking.
3.6. Obsessive-Compulsive Disorder
3.6.1. Dream content. Kuelz et al. (2010) found that compared to healthy controls dreams of OC in- and outpatients contained less positive emotions, also after controlling for dream length and waking-life depressive symptoms. This pertained to the observer ratings, not the patients’ self-ratings. No difference in negative emotions were found between the groups. Similarly, Sauteraud et al. (2001) found no difference in anxiety, sadness or the expression of failure between OC outpatients and healthy controls.
In the study by Kuelz et al. (2010) the OC inpatients, in the second week of their hospitalization, had higher levels of OC content in their dreams compared to healthy controls, whereas the OC outpatients did not. Sauteraud et al. (2001) did not find any difference in OC themes between dreams of controls and OC outpatients in treatment.
Kuelz et al. (2010) further found that the patients’ dreams had non-significant trends toward being less complex and having slightly less affective intensity. Two thirds of the
patients reported that in the past three months before the study they were not able to remember their dreams, or they dreamed equally often in black and white as in color.
None of the healthy controls reported dreaming in black and white.
3.6.2. Effect of therapy on dreaming. Kuelz et al. (2010) found that OC themes in the patients’ dreams reduced during the first five days of exposure treatment.
The level of positive emotions, however, stayed the same during treatment (being lower than healthy controls), while negative emotions showed a small, non-significant
reduction.
In short, few differences are found between dreams of OC patients and healthy controls. The patients’ dreams might contain less positive emotions, more often be black and white, and at times contain more OC content, but more studies are needed for any conclusions to be drawn.
4. Discussion
The following discussion will be divided in three parts. In the first part, the main findings for each disorder that seem to indicate continuity between waking and
dreaming will be highlighted and discussed. In the second part, the same will be done with the findings that seem to indicate discontinuities. In the final part, the possible implications for the continuity between waking and dreaming and the implications for future research will be discussed.
4.1. Findings Supporting the Continuity Between Waking and Dreaming 4.1.1. Schizophrenia. The increased hostility in dreams of schizophrenics (Kramer, 2010) might be a reflection of the common schizophrenic symptom of expecting hostility from others ("persecutory delusions"; American Psychiatric
Association, 2013), indicating continuity. Similarly, the increased number of strangers
(Kramer, 2010; Lusignan et al., 2009) and reduced number of friends (Khazaie et al., 2012; Okuma et al., 1970) in schizophrenics’ dreams can be a reflection of the lack of social relations in these patients’ lives. These two findings can also reflect the hospital setting many of the schizophrenic subjects resided in at the time of dream collection might also, as hospitalized patients are constantly interacting with unknown people (staff, other patients and their visitors). The fact that many of the schizophrenics are residing in hospitals at the time of the studies may also explain the majority of the schizophrenics’ dream scenes being located indoors (Zanasi et al., 2011). This would indicate continuity of actual experiences or circumstances. Another possibility is that these indoor dreams reflect the schizophrenics’ negative symptoms of social
withdrawal, isolation and difficulties with interpersonal interactions (Zanasi et al., 2011).
Other possible reflections of negative schizophrenic symptoms are reduced involvement and emotional expression in their dreams (Hadjez et al., 2003; Zanasi et al., 2011). These two findings more or less corresponds to the two most prominent symptoms of schizophrenia; avolition (lack of participation in work or social activities) and diminished emotional expression (American Psychiatric Association, 2013), i.e., indications of continuity.
The schizophrenics’ reduced role as main character in their dreams (Kramer 2010; Zanasi et al. (2011) might reflect continuity with the daytime delusions of not being in control over one’s actions and thoughts common in schizophrenia (American Psychiatric Association, 2013).
Further, Kramer (2010) reported that the level of paranoia seem to be similar in waking and dreaming for schizophrenics, and that content of hallucinations and dreams
have been found to be similar, i.e., clear indications of continuity. Indicative of
continuity is also more anxiety in dreams of schizophrenics (Kramer, 2010), which may simply reflect daytime symptoms of anxiety and phobias common in these patients (American Psychiatric Association, 2013).
4.1.2. Depression. The findings of more negative mood tone in dreams of depressed (Mellen et al., 1993), and negative dream emotions correlating with intensity of depressive symptoms in depressed outpatients (M. Schredl et al., 2009) are clear indications of continuity. However, as will be discussed in the next section, other studies have obtained results contradicting these findings.
Depressed patients having a more passive role in their dreams (Zanasi et al., 2008) seems to be a continuation of their typical lack of planning and initiative. More death content in dreams of depressed patients with a history of suicide attempt (Mellen et al., 1993) also seems indicative of continuity. The same applies to the finding of themes of loss and abandonment in dreams of mildly depressed persons (Mellen et al., 1993), as one can imagine feelings of loneliness (abandonment) as part of a depression.
More physical interaction in depressed patients’ dreams (M. Schredl &
Engelhardt, 2001) might, according to the authors, be a manifestation of a more conflict-laden interaction with others in waking life, which would reflect continuity of social interactions. The finding of less bizarre dreams for depressed patients than for controls (M. Schredl & Engelhardt, 2001) may indicate increasingly realistic portrayals of waking life issues as the emotional distress increases. This assumption is supported by M. Schredl, Pallmer, and Montasser (1996) demonstrating an association between high levels of general anxiety and more realistic bad dreams. Such portrayals of daytime issues would be examples of continuation of concerns and difficulties.
Dream emotions becoming more positive as daytime symptoms improve from successful pharmacological therapy (Riemann et al., 1990; M. Schredl et al., 2009) shows a clear relationship of continuity between waking and dreaming. The same goes for Kramer et al. (1968)s study, demonstrating decreased hostility in dreams with medication supported symptom improvement.
4.1.3. Anxiety Disorders. The results of Gentil and Lader (1978) “were consistent with the ‘continuity’ hypothesis of dream function” (p.297), showing a distinct link between daytime attitudes and dream content. The authors hypothesized that the finding of more failure and sadness in dreams of the anxious patients may reflect symptoms of depression often co-occurring with pathological anxiety, which would be a continuation of daytime symptoms. The authors also suggested that there was continuity between more aggression directed toward the dreamer in the patients’
dreams and the findings of Beck, Laude, and Bohnert (1974) demonstrating that anxious patients frequently anticipated physical harm and psychosocial trauma. Similarly, less friendly and more aggressive interactions in the patients’ dreams may reflect their negative interpersonal expectations in daytime. The finding of less success and activity in the anxious patients’ dreams might be viewed as a continuation of their feeling of not coping with their fears, and strategies of avoidance frequent in anxiety disorders
(American Psychiatric Association, 2013; Behar, DiMarco, Hekler, Mohlman, &
Staples, 2009).
All the correlations between dream content and daytime attitudes (Gentil &
Lader, 1978) further demonstrates the continuity between waking and dreaming in this sample of anxiety patients.
4.1.4. Personality Disorders. More negative dream emotions (M. Schredl et al., 2012) and more distressing dreams (Simor et al., 2010) in BPD patients might simply express more negative and distressing daytime emotions as a result of their illness, which would be continuity of emotions. More health related topics in dreams of BPD patients might reflect the distress from being mentally ill (M. Schredl et al., 2012), reflecting continuity of concerns.
Simor and Horvath (2013) hypothesized that the cause of the heightened
prevalence of nightmares in BPD patients (Mellen et al., 1993; M. Schredl et al., 2012;
Semiz et al., 2008; Simor et al., 2010; Simor & Horvath, 2013) may be that the dreams depict traumatic childhood experiences typical of BPD patients (Ball & Links, 2009), as dreams have been shown to portray the main emotional and interpersonal concerns of the dreamer (Cartwright et al., 2006).
4.1.5. Eating disorders. More food in eating disordered patients’ dreams (Kramer, 2010; Mellen et al., 1993; Zanasi et al., 2010) is a clear indication of continuity between waking and dreaming. The dream difference, in which bulimics dream more about food and anorexics more of rejecting food, seems also concordant with the diagnoses, in which anorexics are more restrictive of food intake (American Psychiatric Association, 2013). The frequent dreams of body distortions (Brink &
Allan, 1992; Frayn, 1991) also seem quite obvious in terms of its continuity, as a distorted body image is a symptom of eating disorders. Moreover, increased anxiety in dreams of anorexics (Kramer, 2000) seems continuous with the comorbid anxiety disorders frequent in these patients (American Psychiatric Association, 2013).
According to the textual analysis of Zanasi et al. (2010), their finding of the anorexic patients reporting their dreams more often in present tense is an indication of
less empathic abilities. This is continuous with the finding of less empathy in anorexics than healthy controls (Morris, Bramham, Smith, & Tchanturia, 2013). The patients’
dreams further lacked context indicators in their dreams, making the dreamer poorly placed in the narrative of the dream (Zanasi et al., 2010). The authors suggested that this, in conjunction with the anorexics’ nonlinear dream narratives, reflects the anorexic patients constantly doubting themselves and feeling inadequate, creating “the unsteady representation of the outer and inner world distinctive of anorexic subjects” (Zanasi et al., 2010, p.9). This would express continuation of subjective experience and self- conception. Zanasi et al. (2010) further connect the reduced expression of emotions characteristic of the patients’ dreams with the symptom of alexithymia (difficulty with understanding and expressing emotions) often associated with anorexia (Cochrane, Brewerton, Wilson, & Hodges, 1993). The opposite findings, of more emotionality and increased emotional intensity in eating disordered patients’ dreams (Brink & Allan, 1992; Frayn, 1991; Mellen et al. 1993; Schredl & Montasser, 1999) might be a continuation of the unstable emotions and difficulties with emotion regulation in bulimics (Johnson & Larson, 1982; Whiteside et al., 2007).
The scenarios and themes in dreams of the eating disordered women in the studies of Brink and Allan (1992) and Brink et al. (1995), mentioned in the result section, are in line with studies of eating disordered women’s personality characteristics (Lehman & Rodin, 1989; McLaughlin, Karp, & Herzog, 1985; Sheppy, 1985; Strauss &
Ryan, 1987; Williams et al., 1993), suggesting continuity of self-conceptions, conceptions of other people and of the world (Hall, 1953). In addition, the frequent theme of ineffectiveness in their dreams (Brink & Allan, 1992) seems to be a continuation of the feelings of ineffectiveness associated with anorexia (American
Psychiatric Association, 2013). The eating disordered patients being more alone (Enke, Ohlmeier, & Nast, 1968, cited in: Schredl & Montasser, 1999) corresponds to the general feeling of alienation and loneliness found in anorexic patients (Sheppy, 1985).
Furthermore, the increased frequency of negative emotions in dreams of eating disordered patients (Brink & Allan, 1992; Frayn, 1991; M. Schredl & Montasser, 1999) can be seen as a reflection of the comorbid depression prevalent in these patients (Casper, 1998), as well as eating disordered patients’ intense fear of gaining weight.
Schredl and Montasser (1999) proposes that fewer males and less verbal interaction in dreams of anorexics may express a tendency for social withdrawal, possibly reflecting continuity of actual daytime behavior.
4.1.6. Obsessive-compulsive disorder. Kuelz et al. (2010) suggested that the high frequency of OC content in the dreams of the OC patients at the beginning of hospitalization can be interpreted as a reflection of the patients’ preoccupation with their illness, which would be continuation of concerns. Lastly, the reduced level of positive emotions in dreams of OC patients compared to controls is not surprising, considering the fact that emotional well-being in these patients have been found to be reduced (Eisen et al., 2006). Thus, this finding seems to indicate continuity of emotions.
Briefly summarized, there are several instances of continuity in dreams of all the patient groups included. The number of continuity examples vary between the disorders, but this variation more or less corresponds to the number of studies available on the different disorders.
4.2. Findings Reflecting Possible Discontinuities Between Waking and Dreaming 4.2.1. Schizophrenia. More bizarreness in schizophrenics’ dreams can be seen as a continuation of their frequent bizarre delusions (American Psychiatric Association,
2013). However, some studies found equally much (Limosani et al., 2011; Okuma et al., 1970; Scarone et al., 2008) and even less (Hadjez et al., 2003; M. Schredl & Engelhardt, 2001) bizarreness in dreams of schizophrenics than dreams of controls. This is
interesting, and might indicate a ceiling effect; a limit of bizarreness in dreams, beyond which increasing waking thought bizarreness has no influence. The cause and function of such a limit is open for speculation. M. Schredl and Engelhardt (2001) found less bizarreness in dreams of several psychiatric patient groups, and suggested that waking life stressors in patients’ dreams may be reflected in a more realistic manner. As noted previously for less bizarreness in dreams of depressed, perhaps dreams depict daytime issues increasingly realistic as the emotional distress increases, i.e., as the seriousness of the problem increases. However, these mixed findings might reflect methodological issues, or the inadequacy of using diagnostic categories as waking life references (c.f.
Noreika, 2011), an issue that will be dealt with more thoroughly in the discussion. Also intriguing is the finding by Lusignan et al. (2009) of less self-rated bizarreness in dreams of schizophrenics compared to controls and less than ratings by external judges.
This is opposite of the study by M. Schredl and Erlacher (2003) demonstrating that external judges underestimate the level of bizarreness in dreams of healthy individuals compared to the participants’ self-ratings. Possibly the schizophrenics are more used to having strange thoughts, making them underestimate the bizarreness of their dreams.
The schizophrenics rarely being the main character in their dreams (Kramer, 2010; Zanasi et al., 2011) might, rather than being an indication of continuity, be a compensatory reaction to the self-oriented delusions of being exceptional, being the center of attention and so fort, frequent in schizophrenia (American Psychiatric Association, 2013). Moreover, the finding of more family members in dreams of
schizophrenics (Okuma et al., 1970) could also be an expression of discontinuity, as one can imagine schizophrenics not interacting more with their family than healthy people.
Alternatively, this could be an expression of the schizophrenics’ need for support from their family, which makes them think more about their family. This would imply continuity of thoughts (Hall, 1953) and concerns (Domhoff, 1996) rather than actual experiences. Support comes from King’s (2006) finding that reduced emotional wellbeing predicts more familiar characters in dreams.
Hadjez et al. (2003) found no relation between positive psychotic symptoms in schizophrenic adolescents and their measures of dream content. This can indicate that positive schizophrenic symptoms, e.g., hallucinations, have no effect on certain dream content variables, i.e., a discontinuity.
4.2.2. Depression. According to Kramer (2010), less traumatic or depressive content in dream reports of depressed than non-depressed suggests a compensatory relationship between waking and dreaming in depressed. The same applies to the findings of less negative affect in dreams of depressed (Cartwright et al., 2006), and no difference in emotional tone or intensity between dreams of depressed and controls (M.
Schredl & Engelhardt, 2001). Considering the negative waking mood and emotions in depressed, these two findings seem discontinuous on the level of emotions, and might be a dream compensation. Furthermore, these results are in opposition to Gilchrist’s (2013) finding of strong correlations between emotions in waking and dreaming for non-diagnosed individuals, as well as the claim by Hartmann (2011) of there being no discontinuity for emotions. As mentioned, this also contradict findings reported in the previous section (Kramer, 2010; Mellen et al., 1993; M. Schredl et al., 2009). The
reason for these contradictions may be differences between patient samples, and methodological differences between the studies, making replication studies crucial.
The finding of more family members in dreams of depressed (Kramer, 2010) may be indicative of discontinuity, assuming that depressed people do not interact more with their family members in waking life than healthy persons. However, as mentioned for the same finding in schizophrenia, this may instead be an expression of depressed patients thinking more about their family when mentally ill and in need of their support.
This would imply continuity of thoughts (Hall, 1953) and concerns (Domhoff, 1996).
From the perspective of dreams depicting self-conceptions (Hall, 1953), the rare occurrence of hostility and aggressive interactions in dreams of depressed (Kramer, 2010 can be viewed as a compensation (Jung, 1964; Samson & de Koninck, 1986) for the highly negative self-evaluations common in depression (American Psychiatric Association, 2013).
4.2.3. Personality Disorders. The dreams of both the PD patients and controls ended mostly with misfortune (Guralnik et al., 1999). This lack of difference seems counterintuitive, and hence discontinuous, as one can imagine mentally ill patients to view their life as more misfortunate than healthy persons. Another finding contrary to expectations is the one by Schredl et al. (2012), of no typical borderline symptoms in dreams of BPD patients. These findings may suggest a compensatory relationship between dreaming and waking.
The finding of more friendly and less aggressive interactions in the dreams of the PD patients than those of controls (Guralnik et al., 1999) also appear counter intuitive, as impairment in social functioning is a criterion for personality disorders (American Psychiatric Association, 2013). It also conflicts with the results of Pesant
and Zadra (2006) demonstrating hostility and aggressiveness in dreams to be inversely correlated with (daytime) psychological well-being, and one would expect mentally ill persons to feel reduced well-being. Furthermore, the reduced apprehension and
confusion in dreams of the PD patients (Guralnik et al., 1999) seems discontinuous on the level of emotions, as one imagines PD patients to feel more apprehension and confusion in their waking lives than healthy persons.
4.2.5. Eating Disorders. The increased emotionality (Mellen et al., 1993) and emotional intensity (Brink & Allan, 1992; Frayn, 1991; M. Schredl & Montasser, 1999) in dreams of eating disordered patients could, rather than the mentioned continuity, represent a discontinuation and compensation for the difficulty in expressing emotions common in anorexics. The tendency for anorexics to look younger in their dreams than their actual age (Frayn, 1991) is a clear discontinuation of their waking physical appearance. However, considering that this is not a random finding, but a tendency for anorexics to dream specifically of looking younger, this finding questions the
appropriateness of the expression discontinuity. Rather than being a discontinuation of physical appearance, this finding seems more likely to be a continuation of something, e.g., the patients’ feelings of being immature, which would make this finding a
continuation of self-conceptions. This is a hypothesis in need of empirical testing.
4.2.6. Obsessive-Compulsive Disorder. The lack of difference in negative emotions between OC patients and controls (Kuelz et al., 2010; Sauteraud et al., 2001) seems discontinuous, as the negative impact of OCD is substantial, considering its status as one of the most debilitating medical conditions (Murray & Lopez, 1996 in:
Eisen et al., 2006). The finding of no difference in OC themes between dreams of patients and controls (Sauteraud et al., 2001) also seems discontinuous, considering the
amount these patients spend on OC related behavior (the diagnostic criteria is more than 1 hour daily; American Psychiatric Association, 2013).
The reduction of OC content in dreams of OC inpatients during the first days of exposure treatment (Kuelz et al., 2010) is interesting. The authors comment that this reduction could indicate a thorough daytime processing of emotions and issues related to their illness, directly reducing their occurrence in dreams. Such a processing-related reduction would suggest that dreams do not deal with issues that are solved during waking. This notion can be questioned, however, as the treatment was not successfully finished when these dreams were recorded. The patients were in their initial period of treatment, when issues related to the illness probably still were the focus. An alternative explanation is that simply being in a therapy program impacts the general state of mind, making the patient perceive the problem as more solvable (Kuelz et al., 2010). Yet another explanation is that the reduction of OC content in dreams indicates
compensation for the mental overload of focusing on the illness during these days of exposure.
The fact that emotional intensity in dreams did not increase during exposure (Kuelz et al., 2010) is also intriguing, as exposure treatment typically is emotionally strenuous. The possible explanations for this may be the same as mentioned for the previous finding.
In summary, several continuities and discontinuities can be found in dreams of psychiatric patients. The waking life aspects found to be reflected in dreams are emotions, self-conceptions, interpersonal expectations, symptoms, concerns, thoughts, attitudes, personality variables, and actual experiences and circumstances such as social relations, social interactions, behavior patterns, and actual behavior. The variety of
waking life aspects demonstrated here to be continuous in dreams calls attention to the importance of specifying and carefully assessing the aspects of waking life one is searching for manifestations of in the dream. These two issues will be dealt with more thoroughly in later parts of the discussion.
The cited literature on nightmare frequency further supports continuity between waking and dreaming. Compared to the general population, heightened prevalence of nightmares is found in patients with depression (Hublin et al., 1999; Kales et al., 1980;
Mume, 2009; Swart et al., 2013; Zervas & Soldatos, 2005), anxiety (Desroches &
Kaiman, 1964; Nadorff et al., 2013), personality disorders (Mellen et al., 1993) (M.
Schredl et al., 2012; Semiz et al., 2008; Simor et al., 2010; Simor & Horvath, 2013), and schizophrenia (Lusignan et al., 2009), indicating a role for emotional distress in the production of nightmares, as pointed out by Levin and Nielsen (2007). This, in turn, indicates a continuity between negative emotions in waking and dreaming (nightmares).
Another discovery arising from the findings of continuity is that symptoms are reflected in dreams independent of the diagnose. Examples are more family members in dreams of both schizophrenics and depressed, and reduced expression of emotions in dreams of both schizophrenics and eating disordered patients. The finding of increased frequency of nightmares in several disorders also illustrate this point: different
diagnoses have the same effect on dreams (more nightmares). This further underscores the importance of carefully assessing daytime symptoms, to specify what aspects affect the dreams.
A generous amount of discontinuities is identified in addition to the continuities.
This could indicate a compensatory mechanism of dreams. However, it could also be the case that these findings appear discontinuous because of the lack of specifying
which waking life aspects to look for, as well as how the aspects are portrayed by dreams. This issue will be discussed more extensively in the following parts of the discussion.
4.3. Implications for the Continuity Between Waking and Dreaming As mentioned in the previous section, several waking life aspects are found to be reflected in dreams, pointing to the need for a more specific definition of continuity.
This entails specifying which waking life aspects are incorporated into dreams, to what extent, what affects the incorporation rate, and exploring and identifying different ways these aspects can be expressed in dreams. Without a more specific definition of
continuity, the continuities identified (or missed) by different researchers become random, determined by each researchers opinion on what aspects of waking life are manifested in dreams and how they are manifested. This is shown in the present review, in which the continuities reported are based on what was considered by the authors of the studies, as well as the author of the present review, to be expressions of continuity.
In addition to a more specific definition of continuity, there is a need for an understanding of discontinuity. Could the function of an inverse relationship between waking and dreaming for some characteristics be a balancing of the psyche, such that too much of an experience in waking life yields less or none of it in dreaming? This could indicate a compensatory function of dreams (Jung, 1964; Samson & de Koninck, 1986). A different understanding of discontinuous findings comes from viewing dreams as metaphors for emotional states, thoughts and conceptions (Hall, 1953; Hartmann, 1996; Malinowski & Horton, 2011). Hartmann (1996) pointed to the fact that we use metaphors in our everyday speech and thought, e.g., “my boss is a monster”. This was suggested earlier by Calvin Hall (Hall, 1953), viewing dreams as portraying the
